背景:不同病因的肺浸润是低氧性呼吸衰竭导致有创机械通气的主要原因之一。如果肺部浸润原因不明或进展,尽管治疗,肺活检的组织病理学结果可能对治疗改变有显著影响.外科肺活检是常用的技术,但是由于其相当高的发病率和死亡率,微创支气管镜经支气管肺活检(TBLB)可能是一种有价值的选择。
方法:回顾性,单心,机械通气的观察性研究,危重病人,由于2014年1月至2019年7月期间无法解释的肺浸润而接受TBLB。患者的医疗记录进行审查,以获得基线临床特征的数据,TBLB的模态和不良事件(AE),以及组织病理学结果对治疗决策的影响。进行了多变量二元逻辑回归分析,以确定AE和医院死亡率的预测因素,使用Kaplan-Meier方法生成存活曲线。
结果:分析了42例患者在机械通气中位时间为12天后进行了42次TBLB手术,其中16.7%受到免疫抑制,但之前没有肺移植的患者.TBLB的诊断率为88.1%,AE发生率为11.9%(最常见的气胸和少量出血)。92.9%的手术是作为镊子活检进行的,以机化性肺炎(OP)为最常见的组织学诊断(54.8%)。与住院死亡率独立相关的变量是年龄(比值比1.070,95CI1.006-1.138;p=0.031)和存在OP(0.182,[0.036-0.926];p=0.040),后者在生存分析中得到证实(log-rankp=0.040).相比之下,仅基于组织病理学的治疗改变发生在40.5%,并且没有证据表明这些患者的生存率得到改善。
结论:经支气管肺活检仍是机械通气危重患者外科肺活检的一种有价值的替代方法。然而,高诊断率必须权衡潜在的不良事件和组织病理学结果对此类患者治疗决定的有限后果.
BACKGROUND: Pulmonary infiltrates of variable etiology are one of the main reasons for hypoxemic respiratory failure leading to invasive mechanical ventilation. If pulmonary infiltrates remain unexplained or progress despite treatment, the histopathological result of a lung biopsy could have significant impact on change in therapy. Surgical lung biopsy is the commonly used technique, but due to its considerable morbidity and mortality, less invasive bronchoscopic transbronchial lung biopsy (TBLB) may be a valuable alternative.
METHODS: Retrospective, monocentric, observational
study in mechanically ventilated, critically ill patients, subjected to TBLB due to unexplained pulmonary infiltrates in the period January 2014 to July 2019. Patients\' medical records were reviewed to obtain data on baseline clinical characteristics, modality and adverse events (AE) of the TBLB, and impact of the histopathological results on treatment decisions. A multivariable binary logistic regression analysis was performed to identify predictors of AE and hospital mortality, and survival curves were generated using the Kaplan-Meier method.
RESULTS: Forty-two patients with in total 42 TBLB procedures after a median of 12 days of mechanical ventilation were analyzed, of which 16.7% were immunosuppressed, but there was no patient with prior lung transplantation. Diagnostic yield of TBLB was 88.1%, with AE occurring in 11.9% (most common pneumothorax and minor bleeding). 92.9% of the procedures were performed as a forceps biopsy, with organizing pneumonia (OP) as the most common histological diagnosis (54.8%). Variables independently associated with hospital mortality were age (odds ratio 1.070, 95%CI 1.006-1.138; p = 0.031) and the presence of OP (0.182, [0.036-0.926]; p = 0.040), the latter being confirmed in the survival analysis (log-rank p = 0.040). In contrast, a change in therapy based on histopathology alone occurred in 40.5%, and there was no evidence of improved survival in those patients.
CONCLUSIONS: Transbronchial lung biopsy remains a valuable alternative to surgical lung biopsy in mechanically ventilated critically ill patients. However, the high diagnostic yield must be weighed against potential adverse events and limited consequence of the histopathological result regarding treatment decisions in such patients.